Appraisal Form for Identifying

ALS Instructor Potential

With the aid of the ALS Provider Course Results Sheet, an Instructor on the faculty may nominate any candidate
for Instructor Potential selection at the final faculty meeting. Another Instructor must second this nomination
before the candidate can be considered and before this form is required and subsequently completed. All
candidates who self nominate must undergo the rating process but be supported by two Instructors as
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above. If unsuccessful these candidates’ scores must recorded in the Course Directors report and reasons for
non-recommendation explained. This form must be completed in event of faculty or self-nomination for IP status
(it does not need completing for all course candidates).
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Candidate Name
Course Dates
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Course Centre
Nominated by
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Seconded by
In order to be successfully put forward for ALS2/ALS Instructor Potential (IP), the candidate must score
a minimum total of 25, (ALS1/ILS IP must score minimum of 17), and both must score greater than
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83% in their MCQ. Any score of ‘Not Achieved’ excludes the candidate from being selected. Clinical skills should
be evaluated during the performance of the candidate throughout the course. The Course Centre in case of recall
by the Australian Resuscitation Council should retain a copy of each completed form. Please note the clinical
and non-technical skills are continuously assessed throughout the course and not just within the
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specific skill station or when team leading. Scores may be improved over the course with exposure and
practice from the initial skill station. Please read the notes overleaf for further details, and then circle
the appropriate number for each characteristic in the table below.
Not Achieved Achieved Excellent
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MCQ 0 0 2 3
Test Results

Score < 75% 75 - 83% 84 - 91% 92%+

Not Borderline Achieved Excellent
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Achieved
CASTest 0 1 2 3
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Airway 0 1 2 3
Clinical Skills

Initial Resuscitation 0 1 2 3
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Defibrillation 0 1 2 3
Periarrest/Special Circs 0 1 2 3
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CASTeaching 0 1 2 3
Communication 0 1 2 3
Communication

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Interactive and Supportive 0 1 2 3

Team and

Team Member 0 1 2 3
Comments:

Minimum Scores: ALS1 IP: 17 ALS2 IP: 25 TOTAL SCORE

Overall Recommendation for IP (Circle one) ALS ILS NOT Recommended

ARC IP APPRAISAL FORM PAGE 1 OF 4 October 2011
 Identifying ALS Instructor Potential
Please note the clinical and non-technical skills are continuously assessed throughout the course
and not just within the specific skill station or when team leading.

Excellent – Correct decisions made promptly and with confidence. Is able to appropriately expand on
clinical management. An expert or instructor potential performance.
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Achieved – Correct decisions made and performance demonstrated; some hesitation may be evident
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with decision-making or lacking confidence. Standard level of performance expected of an ALS

provider.

Borderline – Minor errors in decision making and performance, hesitant and lacking confidence in
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decisions, required prompting, did not perform skill but recognised error on subsequent questioning.
Basic safe management demonstrated during course. However those skills and attributes often
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mediocre and/or inconsistently demonstrated for the level of performance expected of an ALS provider.

Not achieved – incorrect decision / treatment according to material taught and clinical knowledge,
action may, or likely to cause harm; failed to demonstrate attributes required of an ALS provider. Not
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achieved should be used for unsatisfactory performance.

Explanation of Terms
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Communication
Includes desire to learn to teach and ability to communicate. Should be appropriate and not
overpowering.
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Interactive and Supportive

Includes being approachable and a good listener, with a positive/supportive attitude towards other
participants. Demonstrates ability to promote understanding of core material used on the course.
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Team Member
Shows awareness of the level of understanding of all candidates, especially weaker members and is
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able to provide a supportive role. Provides constructive support to other team members.

Suggestions of where to look for characteristics

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(Evaluation occurs throughout the whole course)

Communication Skills
Questions asked and answered during lectures, participation during discussions, skill stations,
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workshops and CASTeach. Particularly during discussions, skill stations, workshops and CASTeach.

Interactive and Supportive

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Questions asked and answered by the candidate in relation to other participants. Questions asked and
answered during lectures, participation during all discussions including skill stations, workshops and
CASTeach. Support given to others at breaks, supervised practice and within sessions.

Team Member
Particularly demonstrated during CASTeach, but also during skill stations, workshops, discussions and
mentor meetings.

ARC IP APPRAISAL FORM PAGE 2 OF 4 October 2011

 Additional Guidance for Identifying
ALS Instructor Potential
SUGGESTIONS FOR THE SCORING
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MCQ: This is the final score achieved in the post course MCQ only.
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CASTest: This is the overall impression score from the passing CASTest. A four-point scale is
now included to allow instructors to record the quality of the candidate performance. This is included
as a tool to recognise and reward different levels of performance. In the event of a retest candidate
being considered the final passing score is the one recorded.
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Please note the clinical and non-technical skills are continuously assessed throughout the course
and not just within the specific skill station or when team leading. The main advantages of continuous
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assessment are that both candidates and faculty obtain feedback which can then be used to improve
learning, and the final result is based on evidence gathered over the span of the whole learning period.
All criteria should to be assessed over duration of the course and not solely within the specific skills/
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workshop for example.

Airway: Includes the Airway skill station and should be continuously assessed throughout the course.
This includes any opportunity in the CASTeach sessions and others for example the peri-arrest and
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special circumstances when scenarios may have been used. This skill is continuously assessed
throughout the course.

Initial Resuscitation: Includes the ABCDE approach and Basic Life Support and may include
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recognising the need for help and planning for defibrillation to occur, (but not the practical undertaking
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of defibrillation). This should be continuously assessed throughout the course. This includes any
opportunity in the CASTeach sessions and others for example the peri-arrest and special
circumstances when scenarios may have been used. This can be demonstrated directly by
performance of the skills or by aspects such as task allocation and planning.
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Defibrillation: Must be continuously assessed throughout the course. All candidates must be given
opportunity to demonstrate their practical defibrillation skills and perform safe defibrillation with
minimum interruption to chest compressions.
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The practical skills of using an ABCDE approach, CPR, task allocation, planning and
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defibrillation should be taught around a simple simulation during the Initial resuscitation and
defibrillation workshops but this should not the final demonstration of the candidate ability.

Periarrest/Special Circs: included the workshop topics of Arterial Blood Gasses, Bradycardia and
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Cardiac Pacing & Drugs, Tachyarrhythmia as well as all Special Circumstances workshops. The overall
performance in these workshops should be considered. Many candidates and even faculty will have at
least one topic included here as being unfamiliar or new. It is essential to take such factors into
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consideration when scoring as a whole. Additional skills and learning may have been demonstrated in
the final set of CASTeaches where these factors arise again.

CASTeaching: How the candidate facilitates the application of current guidelines and the skills taught
in the workshops / skill stations into the practical management of the patient in cardiac arrest
This includes the candidates’ skills, attitudes and knowledge required to function as a member
of a resuscitation team as well as the team leader. It may also include the candidates’ management of
the post resuscitation and stabilisation phase of the care of the arrested patient.

ARC IP APPRAISAL FORM PAGE 3 OF 4 October 2011

 EXAMPLES FOR THE SCORING OF TEAM AND COMMUNICATION

SCORE 0 IF NO EVIDENCE OF THE CRITERIA ARE APPARENT

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SCORE 1 SCORE 2 SCORE 3

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COMMUNICATION
SOME DIFFICULTY WITH GOOD COMMUNICATION SKILLS CLEAR AND ARTICULATE
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COMMUNICATING WITH FELLOW WITH FELLOW CANDIDATES / COMMUNICATION SKILLS WITH

CANDIDATES / FACULTY FACULTY FELLOW CANDIDATES / FACULTY
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LIMITED SELF AWARENESS OF NON- GOOD NON-VERBAL BEHAVIOUR EXCELLENT NON-VERBAL

VERBAL COMMUNICATION SKILLS (E.G., EYE CONTACT, BODY BEHAVIOUR
LANGUAGE, FACIAL EXPRESSION)
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SOME DIFFICULTY IN ABILITY TO COMMUNICATE WITH EXCELLENT COMMUNICATION

COMMUNICATION ACROSS DIFFERENT STAFF GROUPS SKILLS WITH DIFFERENT STAFF
DIFFERENT STAFF GROUPS GROUPS
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INTERACTIVE AND SUPPORTIVE

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LIMITED INTERACTION WITH FACULTY GOOD INTERACTION WITH FACULTY EXCELLENT INTERACTION WITH
AND PARTICIPATES FULLY DURING AND PARTICIPATES FULLY DURING FACULTY AND PARTICIPATES
SESSIONS SESSIONS FULLY DURING SESSIONS
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LITTLE INTEREST IN LEARNING INTEREST IN LEARNING TO HIGH LEVEL OF INTEREST TO

TO/PARTICIPATING IN TEACHING TEACH/PARTICIPATING IN LEARN TO TEACH/PARTICIPATING
TEACHING IN TEACHING
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TEAM MEMBER
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WORKS IN ISOLATION RATHER THAN WORKS WITH AND IN SUPPORT OF EXCELLENT ENGAGEMENT AND
PART OF THE TEAM THE TEAM SUPPORT TO THE TEAM
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LIMITED UNDERSTANDING OR SOME APPRECIATION OF OTHERS DEMONSTRATES

RECOGNITION OF OTHER TEAM STRENGHTS/WEAKNESSES AND UNDERSTANDING AND
MEMBERS STRENGTHS AND /OR ENCOURAGING TO OTHER TEAM EMPATHETY TO ALL TEAM
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WEAKNESSES MEMBERS MEMBERS FOSTERING GOOD

TEAM BUILDING

ARC IP APPRAISAL FORM PAGE 4 OF 4 October 2011

 Guidelines

Selection of ARC Advanced Life Support Level 1:ILS Instructors

ILS providers may be selected by the ILS faculty as nominated candidates for the ILS Instructor
Course. The Course Director must support the nomination and fully complete this form providing a

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detailed statement of support. In order to be successfully put forward for ILS Instructor training, the
candidate must achieve all ten criteria. This may require exceptional level of performance during

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the course.

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The Course Director of the most recent course must support the nomination and complete this

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form. The Course Director should state the date and centre of the ILS course when completing the
detailed ‘statement of support section’ below. The candidate must achieve all ten criteria.

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Candidate Name

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Candidate email contact:

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ILS Course Centre

Course Date
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Nominated by
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(please print name)

Course Director
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(please print name)

Course Director’s Telephone

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Contact details
Email
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Statement of support from the Course Director

Please give detailed reasons why the above candidate is nominated for the ILS instructor course
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ARC Advanced Life Support level 1: ILS Instructor Nomination - ILS Provider Course May 2011
Immediate Life Support Page 1 of 2
 Essential Attributes – Candidate must meet all ten criteria
1. Registered healthcare professional – Please state Profession/role and professional number below if
known:

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tick
2. Appropriate professional background – should be clinical, would be expected to be

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involved in resuscitation as part of their clinical duties.

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3. ILS or ALS Provider.

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ALS Providers should participate as a observer on a minimum of one ILS course in
the 12 months before attending the ILS Instructor course.

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4. Demonstrated excellent core knowledge in all of the following: the ABCDE approach,
initial resuscitation and defibrillation, airway management, and CASTeach

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5. Credibility – clinical background, minimum 2 years’ post-qualification experience
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6. Demonstrated exceptional ability to communicate at all levels

7. Demonstrated exceptional ability to work as a team member

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8. Already involved in teaching or resuscitation training and shown outstanding teaching

ability
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9. Confident, flexible and adaptable

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10. Interactive and supportive

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Overall Recommendation (tick one) Suitable Not Suitable

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Course Director’s
Signature and Date Date
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Note to Course Directors:

 If you have a registered ILSi planned you should offer the candidate a place on your next ILS
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Instructor course, and ensure they register with the ARC.

 If you do not an ILSi planned, you need to liaise with the ARC to secure your candidate a
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place on their next appropriate instructor course.

 Candidates should not contact the ILSi centre direct in the first instance
 You should then send this form with a copy of the candidate’s ILS or ALS certificate and their
contact details to the ILSi centre.
 To obtain a list of current ILSi centres please email arc@surgeons.org

DO NOT RETURN THIS FORM TO THE AUSTRALAIN RESUSCITATION COUNCIL

YOU SHOULD RETAIN A COPY OF THIS FORM FOR YOUR RECORDS

ARC Advanced Life Support level 1: ILS Instructor Nomination - ILS Provider Course May 2011
Immediate Life Support Page 2 of 2